Medical migration from Zimbabwe: magnitude, causes and impact on the poor

Abstract

This article examines the migration of health professionals from Zimbabwe in the face of a worsening economic and political crisis. Drawing on data from selected health institutions, it shows that the magnitude of this migration is increasing, with no signs of slowing down, and that economic factors are largely responsible. This outflow has negatively affected the users of the health system, particularly the poor who cannot afford the alternative health services offered by the better-staffed and well-equipped private clinics and consequently have resorted to visiting traditional and faith healers. Based on the research findings, the study calls for a speedy resolution of the current economic and political crisis as a long-term solution for reducing the medical brain drain from Zimbabwe.

1. INTRODUCTION

The World Bank (2000) cites the migration of skilled professionals from developing to industrialised countries (the so-called ‘brain drain’) as one of the major forces shaping the landscape of the 21st century. Africa is faced with this large and growing problem (Mutizwa-Mangiza, 1996; Bloom & Standing, 2001). While a number of factors have been blamed for such movement, recent studies have shown that economic push factors are largely responsible for the outflow of skilled professionals from the continent (Gaidzanwa, 1999). This migration has been blamed for worsening the human capital crisis in Africa (Wadda, 2000). For instance, by the late 1980s Africa had lost nearly one-third of its skilled workers, with up to 60 000 middle- and high-level managers migrating to Europe and North America between 1985 and 1990 (World Bank, 2000). In the mid-1990s, Africa was losing about 23 000 professionals annually who were in search of better working conditions in the developed world (World Bank, 1995). The figures show a steady increase in the number of skilled professionals migrating from developing countries.

This migration is often a response to the lack of opportunity in the professionals' home country and the availability of opportunity and deliberate promotion of immigration in the other (Saravia & Miranda, 2004). Hence, a significant ‘brain drain’ of key professionals has been witnessed in Africa, such as engineers and information technologists (Johnson & Regets, 1998), doctors (Grant, 2004) and nurses (Buchan & Sochalski, 2004). These professionals are sometimes replaced by high-cost expatriate professionals: it is estimated that African countries spend nearly $4 billion annually on replacing the professionals lost through migration with expatriates from the West (Commission for Africa, 2005). Expatriates are more expensive to hire than locally trained professionals and the fact that they are prepared to work in the host country for only a limited period makes sustainable economic development even more difficult to achieve.

In Zimbabwe, the increase in the scale of migration of skilled professionals can partly be linked to the adoption of the Economic Structural Adjustment Programme (ESAP) by the government in the early 1990s (Republic of Zimbabwe, 1999). The widely acknowledged failure of this programme saw the standard of living of skilled professionals falling, as the salary benefits could not keep pace with the escalating cost of living. Faced with this situation, most professionals adopted a wide range of livelihood strategies, with some resorting to long-distance international migration. However, no studies to date have attempted to establish the link between migration and poverty in the country. This study seeks to provide the missing link by showing how poverty is influencing the migration of health professionals from Zimbabwe, and how such movement has affected the poor.

Zimbabwe's health sector has been badly affected by the brain drain, with unprecedented opportunities for mobility globally and a marked deterioration in working conditions and prospects at home. In particular, the prevailing political and economic situation in the country is generally seen as a major factor precipitating out-migration. Most of the health professionals who have left Zimbabwe have migrated to countries where their qualifications are recognised, such as the United Kingdom, South Africa and Botswana.

The relatively poor salaries that health professionals in the country are paid compared to those offered to their counterparts in more developed countries have hastened the emigration of health staff. According to a report by a commission tasked to review the country's health services, salaries in the public sector are grossly uncompetitive (Republic of Zimbabwe, 1999). The report shows that a newly qualified doctor in South Africa earns more than twice the salary of the most senior doctor in Zimbabwe (Republic of Zimbabwe, 1999). On the national scale, the World Bank estimated in 1997 that the private to public sector salary ratios were about 2: 1 for nurses and at least 6: 1 for doctors (cited in Republic of Zimbabwe, 1999). Consequently, there have been huge outflows of health professionals from public health institutions to the private sector and beyond the country's borders.

Health professionals in Zimbabwe frequently express their dissatisfaction with their remuneration and working conditions by going on strike, but the government has not been able to effect the required salary hikes because of the current harsh economic climate. In 2001, former Health Minister Dr Timothy Stamps noted that Zimbabwe has been losing an average of 20 per cent of its health-care professionals every year to other countries (Daily News, 17 September 2001). The minister pointed out that each of the country's five major hospitals loses about 24 senior nurses and three doctors every month, leaving the hospitals in a desperate situation. In fact, most of the country's public health institutions are being manned by a skeleton staff that is failing to cope with increased workloads in the face of the growing HIV/AIDS crisis. This has led to low morale and productivity among the workforce and little desire to serve beyond their call for duty.

This article draws on data obtained from a study conducted in 2002 that sought to establish the magnitude and causes of the migration of health professionals from Zimbabwe and to document its impact on the quality of care. It is hoped that the results of the study will help policy makers to make informed policy decisions which will alleviate the plight of public sector health professionals.

2. RESEARCH METHODOLOGY

Five interlinked research instruments were developed in order to better understand the dimensions, causes, impacts and future course of the medical brain drain from Zimbabwe. The first questionnaire (A1) was administered to hospital authorities and to the Ministry of Health and Child Welfare (MoHCW). It asked about staffing patterns at Zimbabwean health institutions over the past decade and the workload of the various health-worker categories at each health institution. The A2 questionnaire was used to interview informants in key positions in the health delivery system. The A3 questionnaire was administered to individual health workers from selected health institutions. The A4 questionnaire was a guide for focus group discussions with key community stakeholders. The A5 questionnaire was administered to emigrant health professionals. The methodologies used to select respondents for each research instrument are outlined below.

2.1 The health institution survey (A1)

Random sampling was used to select health-care facilities. Zimbabwe has ten provinces, seven of which were randomly selected for sampling. In each of the selected provinces, the provincial hospital was selected as well as one district health institution and one health centre. One questionnaire was distributed to each health institution for completion by the hospital superintendent. The provincial hospitals selected for the study are shown in Figure 1.

Figure 1: Location of provincial hospitals selected for the study

The selection of health centres was guided by the authorities interviewed at district centres. One health centre was targeted for each district hospital. Two schools of nursing and midwifery, located at Harare Central Hospital and Mpilo Central Hospital, Bulawayo, were also selected.

2.2 Professional informants (A2)

Interviews were held with professional informants in key positions in the health system. These included personnel from MoHCW, members of professional councils and associations and representatives of partner organisations and the private health sector. The interviews sought to establish the causes of migration and the measures being implemented to reduce such movement.

2.3 Individual health workers (A3)

The A3 questionnaire was administered in the health institutions which had been randomly selected for the A1 questionnaire. It was not possible to obtain data on the number of health professionals employed in each of the selected institutions from the MoHCW. This presented a problem in determining the target number of respondents for each of the institutions. The study thus relied on informal figures presented by people with expert knowledge of staffing patterns in the country's hospitals. In total, 312 people were identified for interviews, including 215 nurses and 59 doctors, and 231 completed questionnaires were returned (a return rate of 75 per cent). Nurses were the largest group of health professionals interviewed, comprising almost 60 per cent of the respondents (Table 1). A smaller number of doctors (13 per cent) were also interviewed, with a smattering of pharmacists, midwives and dentists. Also interviewed were tutors and lecturers, drawn mainly from the nursing schools at Harare and Mpilo Central Hospitals, and some lecturers from the Medical School of the University of Zimbabwe.

Table 1: Employment profile of the respondents

	Frequency	Percentage
Category of health team
Nurse	137	59.3
Midwife	20	8.7
Medical doctor	30	13.0
Pharmacist	10	4.3
Tutor/lecturer	17	7.4
Dentist	5	2.2
Any other category	12	5.2
Type of facility where employed
District hospital	39	16.9
Provincial or regional hospital	117	50.6
Tertiary hospital	41	17.7
Rural health centre	9	3.9
Nursing school in a university	2	0.9
Nursing school not in a university	13	5.6
Medical school	10	4.3
N = 231.

Nearly half the respondents were drawn from provincial hospitals, while others were from district hospitals (16.9 per cent) and tertiary hospitals (17.7 per cent). The remainder were drawn from rural health centres (3.9 per cent), nursing schools (6.5 per cent) and from the Medical School of the University of Zimbabwe (4.3 per cent). The health professionals interviewed are highly qualified: the majority have tertiary diplomas (65.8 per cent) and 19.9 per cent have bachelors' degrees. Some 6.1 per cent have tertiary certificates and 1.3 per cent have other qualifications. Noteworthy are the 5.2 per cent who have masters' degrees and the 1.7 per cent who have doctorates.

2.4 Focus groups (A4)

The focus group discussions were held in Epworth, a suburb just outside the administrative boundary of Harare, the capital. Three focus groups were held with the participants identified in Table 2.

Table 2: Breakdown of participants in focus groups

Group	Composition
1 (n = 12)	• Religious leaders (2)
	• Senior teacher/teacher in charge (1)
	• Traditional healer/practitioner (1)
	• Community representatives/clubs (2)
	• Home based caregivers (3)
	• Traditional midwives (2)
	• Village community worker (1)
2 (n = 12)	Adolescent users of health services (6 females, 6 males, ages 15–19 years)
3 (n = 12)	Adult users of health services (6 women of child-bearing age, 30^+ years; 6 men, 30–50^+ years)
N = 36.

2.5 Emigrant health professionals (A5)

The A5 research instrument was designed to survey doctors, nurses and pharmacists living outside the country. However, response rates were extremely low. Only 25 completed questionnaires were returned. More research is clearly needed in this area.

3. STAFFING ZIMBABWE's HEALTH SECTOR

The magnitude of migration from Zimbabwe's health sector is difficult to establish because of a lack of reliable data. This is further compounded by the fact that departing health professionals rarely declare their intention to migrate when they resign from public sector jobs. In 2002, in the United Kingdom alone, 2346 work permits were issued to nurses from Zimbabwe (Table 3). Zimbabwe was the UK's fourth largest supplier of overseas nurses, after the Philippines, India and South Africa.

Table 3: Work permits issued to nurses in UK, 2002

Country	No. of work permits issued
Philippines	10 424
India	3392
South Africa	2835
Zimbabwe	2346
Nigeria	1501
Ghana	528
Australia	503
Pakistan	385
Kenya	354
Mauritius	351
Other	2983
Total	25 602
Source: Dovlo, 2003: 9.

In order to review trends in the migration of health professionals, the study analysed changes in the number of registered professionals. The data were obtained from the Central Statistical Office and covered the period 1995–2000. The study also analysed the staffing trends in the public sector, which is the principal provider of health services in Zimbabwe. These data were obtained from the MoHCW using the A1 questionnaire.

Figure 2 shows that the number of registered medical practitioners countrywide increased slightly from 1575 in 1995 to 1629 in 2000 (a 3 per cent increase). This small increase was despite the fact that the Medical School of the University of Zimbabwe trains between 80 and 90 doctors every year. There was an overall increase of only 54 doctors (rather than the expected 360 or so) over the four-year period, which suggests that emigration is at least partly responsible. The data also shows a general decline in the number of doctors employed in the public sector over time. For instance, the number of doctors employed countrywide in public health institutions fell from 742 in 1997 to 692 in 1998 (a loss of nearly 7 per cent). The figure rose to 742 in 2000, a staffing level which had been attained three years previously.

Figure 2: Medical practitioners in Zimbabwe, 1995–2000

A comparison of the number of registered medical practitioners in the country and those employed in public health institutions shows that the public sector is in crisis because of its failure to retain staff, leading to an ‘internal brain drain’ to the private sector. In 1997, for example, there were 831 private and 742 public sector doctors. Two years later the figures were 945 and 711, respectively, suggesting that the private sector has been growing at the expense of the public sector. Such movement has left most public health institutions running on a skeleton staff. In fact, the public health institutions employed only 28.7 per cent of the required number of doctors in 1997 (Republic of Zimbabwe, 1999). In the same year, it was estimated that the public sector employed only 34 per cent of the medical doctors registered in the country (Republic of Zimbabwe, 1999). The rest were employed in the private sector.

Figure 3 shows that the total number of registered nursing professionals in the country was stable up to the late 1990s, after which a significant decline was experienced. While there were 15 476 registered nurses in Zimbabwe in 1999, only 12 477 remained by 2001. Such a sudden decline is a cause for concern and is clearly the result of nurses emigrating from the country. On the other hand, the number of nurses employed in the public health sector fell from a peak of 8662 in 1996 to 7007 in 1999 (a decline of 1655 or 19.1 per cent). This decline occurred during a period when 1370 nurses were produced by the country's public training institutions. While some of the nurses might have left the public sector through attrition (such as retirement and death) or moving to the private sector, a significant proportion of the loss may be blamed on emigration.

Figure 3: Nurses in Zimbabwe, 1995–2000

Further evidence that nurses have been moving to the private sector is provided by the number of nurses registered nationally, which rose marginally from 15 096 in 1995 to 15 476 in 1999 (an increase of 2.5 per cent), while the number of nurses employed in the public health institutions declined from 8635 in 1995 to 7007 in 1999 (a decline of 19 per cent). Symptomatic of the growing staffing crisis in Zimbabwe's public health sector is the fact that only 28.7 per cent of the available posts for doctors were filled in 1997 (Table 4). Dentists, pharmacists and even nurses were also in short supply. Of the 1634 doctors registered in the country in 1997, only 551 (33.7 per cent) were employed in the public sector.

Table 4: Health professionals employed in the public sector, 1997

	No. registered in the country	MoHCW requirement	Approved posts	Filled posts	% of requirement filled
Doctors	1634	1851	676	551	28.7
Nurses	16,407	14,251	7923	7923	55.6
Pharmacists	524	198	59	37	18.7
Dentists	148	43	14	14	32.6
Source: Republic of Zimbabwe, 1999.

4. MIGRATION INTENTIONS

An examination of Zimbabwean health professionals' intentions to migrate provides a useful indication of probable future brain drain patterns. The migration intentions measured included migration to the private sector as well as long-distance international migration.

The survey results showed that 68 per cent of the health professionals were considering leaving their public sector jobs in pursuit of better-paying jobs in the private sector, for various reasons. Most of them argued that the public sector does not offer competitive salaries (87 per cent) (Table 5). They find it difficult to live on the salary which they are receiving (68 per cent) and concurred that it is necessary for public health sector professionals to perform two or more jobs to make ends meet (79 per cent). They would prefer to stay in the public sector if they were offered better salaries (87 per cent). The private sector clearly offers better fringe benefits than the public sector. The respondents also expressed fears about their social security in old age, with 81 per cent indicating that they are afraid they will not be adequately provided for when they retire. Hence, the public sector is largely left with people who are poorly paid and poorly motivated to perform their duties.

Table 5: Employment benefits

Do you agree with the following statements?	Yes (%)
The public health sector does not offer competitive salaries to health workers in this country	87
If I received a better salary, I would be happy to stay in my present position	87
I worry that I will not be adequately provided for when I retire	81
If you work in the public health service, it is necessary to do two (or more) jobs to make ends meet	79
The private sector offers better fringe benefits to health workers in this country than the public sector	78
I am considering moving to the private sector because I will receive a better salary	68
I find it difficult to live on the salary I receive	68
N = 231.

The survey results also show that the majority of the health professionals interviewed (68 per cent) are considering leaving the country in the near future. In the case of nurses, the figure is 71 per cent, suggesting that the likelihood of nurses emigrating is high. The most likely destination is the United Kingdom (29 per cent) (Figure 4). However, a sizeable number prefer destinations within Africa (mostly South Africa, followed by Botswana). Other fairly popular intended destinations are Australia (6 per cent), the United States (5 per cent), New Zealand (2 per cent) and Canada (2 per cent). Even though intentions do not automatically translate into action, the extent of dissatisfaction in the health sector is clearly massive. This makes it imperative for policy makers to implement policies that address the welfare and other concerns of health professionals.

Figure 4: Most likely destinations of Zimbabwean health professionals

The survey also sought to establish the broad causes of health professionals' disenchantment. These can be grouped into economic, political, professional and social factors, as shown in Table 6. More than half the respondents (55 per cent) cited economic factors as a reason for wanting to leave the country. These included the desire to receive better remuneration in the intended country of destination (55 per cent) or to save money quickly for later use in the home country (54 per cent). Political factors cited included the general sense of despondency (24 per cent) and the high levels of crime and violence in the country (23 per cent). Professional factors influencing emigration included heavy workloads (39 per cent) and insufficient opportunities for promotion and self-improvement (32 per cent). Lastly, social factors cited included the desire to find better living conditions (47 per cent) and family-related reasons (10 per cent).

Table 6: Reason for intention to move

Reason	Percentage
Economic	55
Because I will receive better remuneration in another country	55
Because of a general decline in the economic situation in this country	55
To save money quickly in order to buy a car, pay off a home loan, or for a similar reason	54
Political	31
Because I see no future in this country	45
Because there is a general sense of despondency in this country	24
Because of the high levels of violence and crime in this country	23
Professional	30
Because of a lack of resources and facilities within the health care system of this country	45
Because there is a general decline in the health care services of this country	43
Because the workload in the health services of this country is too heavy	39
Because of insufficient opportunities for promotion and self-improvement	32
To gain experience abroad	32
Because of the poor management of the health services in this country	31
Because I need to upgrade my professional qualifications due to the unsatisfactory  quality of education and training in this country	23
Because I cannot find a suitable job in this country	11
Because an unacceptable work tempo is expected of me in this country	10
Social	24
In order to find better living conditions	47
Because the value systems in this country have declined to such an extent that I can no  longer see my way clear to remain here	32
To ensure a safer environment for my children	25
In order to travel and see the world	15
In order to join family/friends abroad	14
Because of family-related matters	10
N = 231.
Note: Question is multiple response.

Without question, economic factors have exerted the greatest influence on health professionals' decision to migrate. This is in line with the general decline in the country's economic conditions since the late 1990s. Political factors also gained greater prominence as the country's major political parties fought fierce battles, first in the 2000 parliamentary elections and then in the 2002 presidential elections. These campaigns were associated with widespread violence, which was more severe in rural areas. This saw many professionals fleeing the countryside for their safety and that of their children. Still other health professionals are migrating because of professional factors. Most of these factors relate to the poor economic conditions prevailing in the country which have resulted in a general decline in health-care services.

Interviews with emigrant health professionals confirmed that economic and political factors were the main reasons they had left the country (Table 7). Economic factors cited included low remuneration (56 per cent) and the general decline in the economic situation at home (40 per cent). Political factors included the high levels of crime and violence (politically related) (48 per cent) and the fact that they saw no future in the country (48 per cent). The dominant professional factors cited were the general decline in health services in the country (44 per cent), poor management of health services (36 per cent) and the need to gain experience abroad (24 per cent). Lastly, social factors which had significantly influenced these health professionals' decision to emigrate were the need to find better living conditions (48 per cent) and family-related matters (12 per cent).

Table 7: Reasons for leaving the home country

Reason	Yes (%)
Economic factors	40
Political factors	36
Professional factors	25
Social factors	16
N = 25.
Note: Question is multiple response.

5. EFFECTS OF MIGRATION

The shortage of skilled health professionals has had a negative impact on the workloads of the staff who choose not to migrate (Republic of Zimbabwe, 1999). The shortage of doctors nationally in public health institutions has increased the workloads of medical practitioners. The MoHCW estimates the current doctor to patient ratio as one doctor to 6000 patients, but this study established that this is not common at all levels of health care. Data on doctors' workloads showed that those employed in district hospitals have heavier workloads than those in provincial and central hospitals (Table 8). While the outpatient attendance per doctor at Gweru Provincial Hospital was 1: 20 858 in 1999, the attendance per doctor at Kadoma District Hospital was 1: 30 015. Doctors posted in areas with lower levels of development clearly have a much heavier workload than those employed in more developed city areas.

Table 8: Patient attendance at selected health institutions in Zimbabwe

		Variable	1998	1999	2000
Doctors	Gweru Provincial Hospital	No. of outpatients	145 220	149 221	51 001
		No. at post	7	8	8
		Outpatient attendance/doctor	20 746	18 653	8650
	Kadoma District Hospital	No. of outpatients	171 372	168 522	155 462
		No. at post	7	6	6
		Outpatient attendance/doctor	24 482	28 087	2 5910
Nurses	Gweru Provincial Hospital	No. of outpatients	23 110	23 177	2 3428
		No. at post	238	232	235
		Outpatient attendance/nurse	97	100	100
	Kadoma District Hospital	No. of outpatients	171 372	168 522	155 462
		No. at post	105	113	112
		Outpatient attendance/nurse	1632	1491	1388
	Epworth Polyclinic	No. of outpatients	22 440	38 000	42 000
		No. at post	5	5	4
		Outpatient attendance/nurse	4488	7600	10 500

In Zimbabwe, nurses form the backbone of the country's health delivery system and they run most of the health centres in disadvantaged rural areas. Chasokela (2001) notes that nurses working in rural areas have over the years functioned in an increasingly expanded role, taking on the roles of pharmacist, doctor, physiotherapist and so forth. This has increased the workloads of nurses stationed in the less attractive regions.

The MoHCW estimates that the current nurse: patient ratio is one nurse to 700 patients (Republic of Zimbabwe, 1999), but this study established that nurses employed at provincial health institutions have nurse: patient ratios lower than the national average. For example, in 2000 the nurse: patient ratio for Gweru Provincial Hospital was 1: 100 (less than the national average), compared with the nurse: patient ratio of 1: 1388 at Kadoma District Hospital (nearly twice the national average). The situation is worse for nurses employed at the health centres where doctor visits are rare. Thus, the nurse: patient attendance ratio in 2000 at Waverly Clinic (a health centre in Kadoma) stood at 1: 7500 (more than ten times the national average) and at 1: 10 500 for Epworth Polyclinic (an underdeveloped health centre situated at the outskirts of Harare). Nurses employed at health centres endure very heavy workloads, but the situation improves significantly as one moves to the district and provincial health institutions. The study also established that less qualified staff (nurse aides) are carrying out nursing duties at rural health centres owing to the shortage of qualified health professionals.

Poor job satisfaction and low morale are endemic among health professionals in southern Africa (Bloom & Standing, 2001). This study established that health professionals who remain in public employment increasingly seek ways to augment their salaries. These include moonlighting in private facilities and attending to non-medical businesses. While doctors have been able to establish private surgeries, nurses in Zimbabwe have been hampered from doing so by the current legal framework. Hence, for most nurses, migrating to the private sector remains the only viable option. However, some public sector health nurses who choose not to migrate to the private sector are engaged in part-time work in the private sector to augment their salaries. This affects their performance in their public sector jobs. In the focus groups it was alleged that ‘nurses in the public sector are engaging in a lot of part-time work in private clinics. By the time they come for their normal duties, they will be too tired to work. That is why we get poor service when we visit the clinic’.

The migration of skilled health professionals from the country has adversely affected the quality of care offered in the health institutions. Consultation time available to patients has been reduced owing to the work pressure faced by the few remaining health workers. One participant in the focus group pointed out that ‘the shortage of nurses at the clinic means that patients have to wait for a long time before receiving medical treatment. When a patient eventually receives treatment, consultation is usually done hurriedly as the nurses work at a fast pace so as attend to a “multitude” of other patients waiting to receive the same service’.

The effects of the migration of health professionals on the main users of public health institutions have been many and varied. For instance, patients now have to wait for long periods of time before receiving medical attention. Some respondents noted that some patients spend practically the whole day waiting to receive medical attention. This time could have been spent on other income-generating activities and therefore has serious implications for the food security of poor households which are engaged in a daily struggle for survival. Consequently, they sink deeper into poverty.

Some focus group respondents complained that they have to walk long distances in search of health institutions with adequate health services. They noted that the local health centre is severely understaffed and patients do not receive quality health care as they are sometimes attended to by the less qualified nurse aides. In addition, they also complained that they no longer receive health education from the health professionals as they will be too busy attending to patients.

Health professionals' migration has severely compromised the quality of service provided to patients. Better-trained and experienced professionals are lost from the public health sector as the economic crisis in the country continues to worsen. The burden of taking care of the public health system users has fallen upon the inexperienced junior doctors. While these have performed reasonably well in the prevailing circumstances, service delivery in major hospitals has sometimes ground to a halt as they engage in industrial action to press for better salaries and conditions of service. Private health institutions have benefited from the disgruntlement of public sector health professionals, many of whom they have recruited by offering attractive packages and better working conditions. Unfortunately, the poor are unable to access the health services these institutions offer as they charge exorbitant fees.

The role of traditional healers in contemporary society has diminished with the introduction of modern allopathic medicine. However, in recent years traditional healers in Zimbabwe have begun to play an increasingly important role owing to the collapse of the formal health-care system. During the focus group discussions, it emerged that the shortage of health professionals in public health institutions has made it necessary for patients to seek alternative forms of health care. The poor, who cannot afford the high consultation fees charged in private health institutions, have resorted to visiting traditional and faith healers who charge affordable rates. Long queues can be observed at the residences of traditional and faith healers, which clearly attests to their popularity. Some traditional healers also claim to cure HIV/AIDS, a claim which has brought them considerable business in the face of the growing HIV/AIDS crisis in the country. Thus the poor find themselves without formal health-care services and resort to the informal sector.

6. CONCLUSION

This article has provided an overview of the trends and effects of health professionals' migration from Zimbabwe. On a national scale, health professionals are moving to the private sector, which offers higher salaries and better working conditions. Some who choose not to migrate from the public sector are engaged in part-time work in private health institutions, with negative effects on their public sector jobs. Nurses showed a higher likelihood of emigrating, suggesting that nurses in Zimbabwe are highly dissatisfied with their current conditions. The major push factors cited are economic, while political and professional factors also ranked high. The shortage of health professionals has resulted in increased workloads for those who remain. The migration has had the greatest impact on the poor, who rely on the health services offered by public health institutions at subsidised rates. The remaining health professionals are failing to cope and patients have to wait a long time before receiving medical attention. As a result, some patients have turned to traditional and faith healers where they are attended to at affordable rates. Studies such as this should help policy makers to make informed policy decisions in order to alleviate the plight of the main users of public health institutions: the poor.

Notes

¹PhD student, Department of Geography, University of Western Ontario, Canada. The author wishes to thank the World Health Organisation (WHO) AFRO Region for funding the study through the Division of Health Systems and Services Development. The author also gratefully acknowledges the technical assistance of Professor Jane Mutambirwa in conducting the study.